Physiatric Approaches to the Management of Low Back Pain: Applying CPG to our Clinical Practice

Joseph Feinberg, M.D.

Evidence Based Medicine vs Judgment Based Medicine

How do guidelines affect our decisions?

Where is the science?

How do we weigh our judgment that at times is as much intuitive as it is scientific?

Does relying on pure science undermine practicing medicine as an art?

Do the guidelines address the outline questions?

Applying CPG to Our Clinical Practice

Ordering imaging studies

a. Plain X rays – how often do they affect our decision?

b. MRI

i. In the absence of concerns for a malignancy or infection and before considering an injection does it play a role in conservative care?

ii. In the absence of neurological findings does it add value (press ganey)?

Ordering Electrodiagnostics

a. In the absence of neurological sxs do they play a role?

b. In the absence of neurological exam findings do they play a role?

c. When do they contribute to the clinical plan?

Applying CPG to Our Clinical Practice

Applying CPG to Our Clinical Practice

Prescribing PT

a. Do different approaches give different outcomes?

b. How many sessions do patients really need?

c. When does the argument “I need someone to help make sure I do my exercises” justify ordering PT (press ganey scores)

Prescribing chiropractor care

a. Does CP care offer something different?

Prescribing acupuncture

a. What criteria determine who is a candidate for acupuncture?

b. Is it disease specific or personality (psychological) dependent?

Prescribing oral medicationsa. Should NSAIDS be taken in sustained way to decr inflammation or prn for

pain?

b. What is the role for narcotics & do they lower pain threshold (press ganey)?

c. What’s the threshold for oral steroids & how often can they be repeated?

Prescribing spine interventional proceduresa. Can epidural impact neurological deficits?

b. Is there truly an amount that is unsafe?

Referring to a spine surgeona. In the absence of an obvious surgical l emergency (i.e. cauda equina

syndrome) when should a spine surgeon be engaged in the patient’s care?

Patient expectationsa. How much do patient expectations affect our decisions and determine what

pathway of care is most appropriate and most effective?

Grading the Studies

Level 1 studies – high quality randomized controlled trial or systematic review of level I RCT Level 2 studies – lesser quality RCT or prospective comparative study or systematic review of level II or level I Level 3 studies – case control Level 4 studies – case series  Level 5 – expert consensus

Grading Recommendations

Level A - Recommended - Good Evidence 

Two or more consistent Level I studies  Level B - Suggested – Fair Evidence 

One Level I study with additional supporting Level II or Level IIITwo or more consistent Level II or III studies

  Level C - May be considered and is an option – Poor Quality Evidence 

One Level I, II or III study with additional supporting Level IV studiesTwo or more consistent Level IV studies

 I (Insufficient or conflicting evidence) – Insufficient evidence to make recommendations for or against 

A Level I, II, III or IV study without other supporting evidenceMore than one study with inconsistent findings

Degenerative Spinal Stenosis CPG Guidelines 2011Kreiner et al. Spine J, 2013 Jul 13 (7) 734-43 (most current publication)Endorsed by AAPM&R (on AAPM&R and NASS website)

a. Defined as diminished space secondary to degenerative changes in spinal canal that can cause gluteal or lower limb pain

b. Natural history is favorable in 33-50% of patients with mild to moderate stenosis (Consensus statement)

c. PE findings are inconclusive for making dx (Insufficient evidence)

Imaging

i. Radiographs not routinely neededii.MRI, CT (when MRI contraindicated)

a. probably unnecessary in early managementb. useful for making diagnosis in patients with positive clinical history and exam for stenosisc. correlation of clinical symptoms with anatomic narrowing (Insufficient evidence)

EDXi. EMG (paraspinal mapping) to confirm dx in mild to moderate sxs

and when there is radiographic evidence (Level B)ii. EMG of limbs and NCS – to dx spinal stenosis but may be helpful to

identify other comorbidities (Inconclusive)

Oral Medications – inconclusive for all medsi. NSAIDs if no contra-indications (or acetaminophen) ii. Narcoticsiii. gabapentin for short term use for break through iv. Oral steroids depending on severity of symptoms

Rehabilitation i. inconclusive but work group’s opinion is that active PT is an optionii. inconclusive for traction, TENS, E stim

Interventional Spine Proceduresi. Contrast fluoroscopy is recommended for epidurals (Level A)ii.Interlaminar epidural for short term relief (2 wks to 6 mos) and

conflicting evidence for long term (Level B)iii.Multiple injections for long term relief (3 to 36 months) for

radicular or neurogenic claudication sxs (average was 3.6 injections per patient) (Level C)

Medical/Interventionali. can provide long term relief (2-10 years) in a large percentage of

patients (Level C)ii.recommended for patients with mild (Consensus) and with

moderate (Level C) stenosis

Alternative Carei. Acupuncture - inconclusiveii.Manipulation – inconclusive

Bracing LS corset - can reduce pain and increase walking distance (Level B)

Surgeryi. Decompression surgery recommended in moderate to severe

stenosis (Level B)ii.Decompression alone if there is no instability (Level B)

Lumbar Disc Herniation with Radiculopathy (2012)Kreiner et al. Spine J, 2014 Jan 14 (1), 180-91 (most curent publication) 

Radiculopathy defined as pain, numbness or weakness along a dermatomal or myotomal distribution

Natural history – the majority of patients will improve independent (not without) of treatment. This in part is probably do to shrinkage of HNP (Work group consensus statement)

Imagingi. Plain radiographs – no recommendations but probably not needed

in uncomplicated cases (no red flags)ii. MRI (or CT scan) – In patients with history and PE findings c/w

HNP & radiculopathy, MRI (CT or CT myelo when MRI contra-indicated) is recommended to confirm HNP (Level A recommendation)

Physical Exam

i. MMT, sensory testing, supine SLR, Laseque’s sign and crossed Laseque’s sign are recommended to help dx (Level A recommendation)

ii. Supine SLR is suggested over seated SLR for dx (Level B recommendation)

iii. Insufficient evidence to recommend for or against cough impulse test, Bell test, femoral nerve stretch test, slump test, lumbar ROM or absence of reflexes to dx HNP with radiculopathy

EDX i. Recommended to confirm presence of comorbid conditions (Work

group consensus)ii. No statement on role when motor deficits are presentiii. EMG, NCS & F waves have limited utility in dx of HNP with

radiculopathy (Level B)

Oral Medications (insufficient info on all meds)i. NSAIDs, acetaminophenii. Narcoticsiii. gabapentin (insufficient evidence), amitriptyline (insufficient

evidence) iv. Oral steroids

Rehabilitation

i. Insufficient evidence to recommend for or against PT as stand alone txsii. Limited course of structured exercise is an option for patient’s with mild to moderate sxs (Work group consensus)

Interventional Spine Procedures

i. Contrast fluoroscopy recommended for epidural injections (Level A)

ii. Transforaminala. Recommended for short term (2-4 wks) relief (Level A) b. Improve functional outcome in majority (Level B)

iii. Interlaminar epidural may be considered (Level C)

iv. Insufficient evidence for 12 month efficacy

v. No optimal frequency or quantity of injections (Lack of info)

vi. Insufficient evidence for one approach (transforaminal, interlaminar, caudal)

vii. Higher degree of nerve root compression negatively affects outcomes with transforaminal epidurals

Medical/Interventional• Suggested to improve functional outcomes in the majority of

patients (Level B)• Interlaminar considered (Level C)• Medical/Interventional are suggested to improve functional

outcomes (Level B)• Insufficient evidence on the influence of age• Cost-effective for contained herniations but not extrusions

Manipulation• An option for symptomatic relief (Level C)• insufficient for or against to improve functional outcome

Traction – insufficient evidence

Surgery

i. Insufficient evidence for surgery for patients with motor deficits

ii. Surgical intervention recommended before 6 months in patients who symptoms are severe enough (Level B)

Degenerative Lumbar Spondylolisthesis (2008)Endorsed by AAPM&R (on AAPM&R and NASS websites)   

Definitioni. Acquired vertebral displacement associated with degenerative changes

Natural Historyi. Majority of patients without neurologic deficits do well with conservative careii. Patients with neurological changes are more likely to develop functional without surgeryiii. Progression of clinical sxs does not correlate with progression of slip

Clinical Dxi. Patients complain primarily of radiculopathy or neurogenic claudication (usually secondary to associated stenosis) with or without LBPii. No clinical sxs specific and many patients will be asymptomatic

Imagingi. Lateral radiograph is most appropriate test (Level B)ii. MRI (or CT scan) – most appropriate to assess associated spinal stenosis (Consensus)

Physical Exam i. Obtaining an accurate history and PE is essential for dx and plan (Consensus)

EDXi. No comments on EDX

Oral Medications – no commentsi. NSAIDs, acetaminophen

ii. Narcoticsiii. Anticonvulsants, antidepressantsiv. Oral steroids

Rehabilitation i. No conclusive recommendations on PT (paucity of literature)

Interventional Spine Injectionsi. No recommendations on facet inections or RF

Medical/Interventionali. No studies to compare tx to natural history

ii. Tx should be similar to Spinal Stenosis when radicular sxs of stenosis predominate (Consensus)

Alternative Care (no commentary)i. Acupunctureii. Manipulationiii. Massage

Surgery

i. Indicated for low grade deg spondylolisthesis with stenosis in patients recalcitrant to medical/interventional tx (Level B)

ii. Decompression with fusion is better than decompression alone for symptomatic stenosis with degenerative spondylolisthesis (Level B)

Summary Remarks How do these guidelines affect our Clinical Practice? How useful are they and what’s missing?

Some Key Points

1)There is no evidence for or against PT.2)No comment on role of EDX when neuro deficits exist.3)Limited comment on facet injections which are

extremely relevant for spinal stenosis and spondylolisthesis.